Cardiovasc Intervent Radiol (2018) 41:645–652
https://doi.org/10.1007/s00270-017-1860-5
TECHNICAL NOTE
Adult ‘PICC’ Device May be Used as a Tunnelled Central Venous
Catheter in Children
Brooke T. Lawson1 • Ian A. Zealley1
Received: 10 May 2017 / Accepted: 14 December 2017 / Published online: 17 January 2018
 The Author(s) 2018. This article is an open access publication
Abstract
Purpose Central venous access in children, in particular
small children and infants, is challenging. We have
developed a technique employing adult peripherally
inserted central venous catheters (PICCs) as tunnelled
central venous catheters (TCVCs) in children. The princi-
pal advantage of this novel technique is that the removal
technique is less complex than that of conventional cuffed
TCVCs. The catheter can be removed simply by being
pulled out and does not require general anaesthesia. The
purpose of this study is to determine the success, safety and
utility of this technique and to identify the rate of late
complications. We describe the 6-year experience in our
unit.
Materials and Methods Electronic and paper medical
records were reviewed for consecutive paediatric patients
who had a PICC device inserted as a TCVC over a 6-year
period (September 2009 through July 2015). The following
data were recorded—patient demographics, setting for
PICC as TCVC insertion, use of ultrasound and fluo-
roscopy, PICC device type, early or late complications and
date of and reason for removal.
Results Twenty-one PICCs were inserted as TCVCs in 19
children, all aged less than 10 years. Mean patient age at
the time of placement was 3.7 years. Average patient
weight was 15.7 kg. All insertions were successful with no
significant immediate complications recorded. The most
common indication for insertion in our patient sample was
pseudo-obstruction secondary to gastrointestinal
& Brooke T. Lawson
brookelawson@nhs.net
1
Department of Radiology, Ninewells Hospital, Dundee
DD1 9SY, Scotland, UK
dysmotility disorder (24%), with cystic fibrosis infective
exacerbation being the second most frequent diagnosis
(14%). Suspected catheter-related infection led to early
device removal in one case (4.8%). Inadvertent dislodge-
ment occurred in one case (4.8%). Nineteen of the 21
devices (90.4%) lasted for the total intended duration of
use.
Conclusion Using a PICC device as a TCVC in small
children appears to be a safe technique, with an accept-
able complication profile.
Keywords Catheter
Central venous
Paediatrics

Interventional radiology
Complications
Introduction
Intensive treatment of paediatric patients with oncological,
haematological and other complex medical conditions
often relies on durable venous access devices [1]. The
choice of vascular access in infants and children is typi-
cally dictated by the severity of the illness and the expected
duration of the proposed treatment [2]. TCVCs provide
vascular access for frequent blood sampling and adminis-
tration of chemotherapy agents, blood products, antibiotics
and parenteral nutrition [3]. Although establishment of
stable venous access has become integral to the manage-
ment of many long-term illnesses [4], it is recognised that
the process of attaining central venous access in children is
more difficult than in adults because of the smaller vessel
dimensions and the sharper, more angulated routes the
subclavian and internal jugular veins make in infants [5, 6].
TCVCs are usually sited through the internal jugular
vein, and after traversing through a subcutaneous tunnel in
123
646 B. T. Lawson and I. A. Zealley: Adult ‘PICC’ Device may be used as a Tunnelled Central…
the anterior chest wall, exit the skin away from the site
where they enter the vein [4]. Tunnelled femoral PICCs
can be useful, particularly in preterm or very low-birth
weight infants, if there has been failure to insert PICCs in
other peripheral veins or if veins are too small in calibre
relative to size of catheter. Nevertheless, studies have
demonstrated that femoral vein groin-insertion sites are
associated with higher rates of infectious complications
[7, 8].
Conventional TCVCs can prove cumbersome in the
paediatric population and are associated with relatively
high complication rates in smaller children (\ 1 year or
\ 10 kg) [5]. Catheters used as tunnelled central lines
come in a wide range of sizes but are sometimes signifi-
cantly larger than PICC devices because of the direct
puncture into a larger central vein [9]. To overcome some
of these technical issues, our unit has developed a tech-
nique employing adult PICC devices as TCVCs in children.
The main fundamental difference between an adult PICC
device and a conventional paediatric TCVC is that a PICC
device lacks a Dacron cuff. A Dacron cuff mounted on the
catheter scars into the subcutaneous tissues within the
tunnel after several days or weeks, reducing the risk of
inadvertent dislodgement and acting as a barrier to infec-
tion from the skin insertion site [10]. The principal
advantage of using a PICC as TCVC in this population is
that the central catheter can be removed easily in the ward
or community, without needing to bring the patient back to
the radiology department to dissect the cuff free from
adhesions which may require general anaesthesia. PICCs
are available in a large range of sizes, 2–7 French (Fr), and
are available in single- or dual-lumen design [9]. The
smallest PICC catheter diameters compare with the some
of the smallest commercially available paediatric catheters
designed for tunnelling such as the BARD Broviac 2.7 Fr
single-lumen catheter.
It was hoped that the use of PICCs as TCVCs in small
children would be associated with equal durability, com-
parable complication rate, greater convenience and possi-
bly a better cosmetic result in relation to healing of the
chest wall scar in comparison with conventional cuffed
central devices. By durability, we wanted to ascertain
whether catheters lasted for the total intended duration of
use and remained in situ until no longer required
The purpose of this study is to determine the success,
safety and utility of this novel technique, and to identify the
rate of late complications. The outcome was determined as
successful if the catheter was still functioning properly at
the time of removal. We describe the 6-year experience in
out unit.
123
Materials and Methods
Appropriate institutional research approval was obtained
and data gathered retrospectively from electronic and paper
medical records, which were reviewed for consecutive
paediatric patients who had a PICC device inserted as
TCVC over a 6-year period (September 2009 through July
2015).
For each individual case, the decision to use this tech-
nique was made based on the anticipated duration of
treatment. Our technique was carried out when treatment
was expected to be required for longer than a few days (for
which peripheral cannulas would suffice) but shorter than
several months or longer (for which a portacath would be
the preferred device).
The following data were recorded—patient demo-
graphics, setting for PICC as TCVC insertion, use of
ultrasound and fluoroscopy, PICC device type, site of
surgical insertion, early or late complications and date of
and reason for removal. CVC-related complications can be
divided into early complications (mechanical and infective)
and late complications (mechanical and infective). Early
complications are generally secondary to the insertion
procedure. Complications were defined as early if they
occurred in the first week after the CVC insertion; all
complications occurring thereafter were defined as late
complications [11].
Microbiology results were reviewed to identify any
laboratory-confirmed catheter-related infections. Cases in
which complications or misadventure resulted in premature
removal of the catheter were recorded. Data were entered
into an ExcelTM spread sheet and analysed using basic
ExcelTM statistical tools.
Technique
A consultant interventional radiologist carried out all pro-
cedures using an aseptic technique. The preferred site for
access is one of the internal jugular veins, usually the right.
The sizes of adult PICCs used ranged from 3 to 5 Fr
catheters (MedComp/Pro-PICCCT, Mexico). Figure 1
illustrates the details of the procedure step-by-step. Local
anaesthetic is infiltrated from the right internal jugular vein
(RIJV) incision site to a right anterior chest wall (RACW)
exit site. A 21-gauge (G) access needle is passed subcu-
taneously from the RACW site to the RIJV site. After
needle access along the tunnel track has been achieved, a
0.018-inch guidewire is passed through the access needle,
which is then withdrawn. A peel-away sheath/stylet for the
PICC is advanced along the guidewire in the reverse
direction from the RIJV incision to the RACW incision.
A PICC device is passed through the peel-away sheath. The
B. T. Lawson and I. A. Zealley: Adult ‘PICC’ Device may be used as a Tunnelled Central…
Fig. 1 Illustrations demonstrating our novel technique, step-by-step.
A Local anaesthetic is infiltrated from the RIJV incision site to the
RACW exit site, situated approximately midway between the nipple
and axilla, along a 1–2 inch track below which the subcutaneous
tunnel will be fashioned. A small 5 mm RIJV site incision and a
smaller 2 mm RACW site incision are made. B The venous access
needle is tunnelled from the RACW incision to the RIJV entry site
incision. C A 0.018-inch guidewire is passed through the access
needle. D A 5 Fr peel-away sheath is then passed over the guidewire
from the RIJV entry site to the RACW exit site. E The stylet and
guidewire are removed, and a PICC device is passed through the peel-
away sheath from the RACW site to the RIJV site. F The peel-away
peel-away sheath is withdrawn intact and reassembled with
stylet for later use. The PICC is advanced through the peel-
away sheath/stylet subsequently introduced into the RIJV
after central venous access is secured using ultrasound
guidance. The catheter is cut to length using fluoroscopic
guidance (Fig. 2). The peel-away sheath is removed. Skin
closure over the RIJV incision site is achieved with ster-
istrips, and a proprietary adhesive securing device is used
at the RACW incision site (Fig. 3).
647
sheath is then withdrawn off the PICC and reassembled with the stylet
for subsequent use. G The RIJV is then cannulated with a 21 Fr
needle under ultrasound guidance, and a 0.018-inch guidewire is
passed into the right atrium, after which the peel-away sheath
assembly is advanced over the guidewire into the RIJV. H The PICC
is advanced through the peel-away sheath into the RIJV, and the
catheter is cut to appropriate length using fluoroscopic guidance in the
same manner as conventional TCVCs, after which the guidewire and
stylet are removed and the PICC device introduced down the peel-
away sheath into the central veins. I The peel-away sheath is
subsequently removed
Results
Twenty-one PICCs were inserted as TCVCs in 19 children,
all aged less than 10 years. Mean patient age at the time of
placement was 3.7 years (range 1.4 months–9.6 years).
Five patients (24%) were less than 1 year of age or less
than 10 kg in weight. Average patient weight was 15.7 kg.
The most frequent underlying patient conditions that pre-
cipitated the indication for long-term central venous access
was pseudo-obstruction secondary to gastrointestinal dys-
motility disorder in five patients (24%) followed by cystic
fibrosis infective exacerbation in three patients (14%).
Specific indications were for the administration of par-
enteral nutrition in 4/21 cases (19%) and intravenous
123
648 B. T. Lawson and I. A. Zealley: Adult ‘PICC’ Device may be used as a Tunnelled Central…
Fig. 2 Fluoroscopic image demonstrating the tip of the PICC used as
a TCVC at the superior vena cava-right atrium junction. We typically
aim for catheter position in the right atrium
Fig. 3 Post-operative photograph illustrating how the PICC device is secured using the proprietary adhesive dressing supplied with the device,
applied to the RACW. Skin incision closure is achieved with adhesive steristrips
antibiotics and/or antiviral therapy in 17/21 cases (81%).
Figure 4 summarises the indication for catheter insertion.
The total number of catheter days reviewed was 853.
Catheter dwell time ranged from 6 days to 6 months with a
mean catheter dwell time of 41 days. Catheter devices used
included 3 Fr single lumen in three cases (14%), 4 Fr
single-lumen catheters in 14 cases (67%) and 5 Fr dual-
lumen catheters in four cases (19%). Figure 5 summarises
123
catheter size versus patient age at insertion. General
anaesthesia and local anaesthesia were used for all catheter
insertions (100%). The procedure was carried out under
ultrasound and fluoroscopic guidance for 18 (86%) cases,
all in the interventional radiology (IR) suite, and ultrasound
only for three cases (14%), all in the paediatric operating
room (OR) suite. Subsequent conventional X-ray confir-
mation of tip location was obtained in the later cases. The
RIJV was the access site in 19/21 insertions (90%). The left
internal jugular vein (LIJV) was chosen as the access site in
two cases (10%) when there had been prior damage to the
RIJV access site caused by prior venous access procedures.
Figure 4 also summarises the access site used in all
procedures.
All insertions were successful with no significant
immediate or early complications recorded. In our popu-
lation, premature catheter removal occurred in two cases
(9.6%) with an overall late complication rate of 2.3 per
1000 catheter days. Inadvertent catheter dislodgement
occurred in one case (4.8%) at 10 days post-insertion
(dislodgement rate of 1.2 per 1000 catheter days). This case
was a 3-year-old male receiving intravenous antibiotics for
osteomyelitis. We suspect that inadvertent dislodgement
occurred during a change of clothes by the child’s parents.
Early catheter removal at 14 days was performed in one
case (4.8%) for suspected catheter-related infection (sus-
pected catheter-related infection rate of 1.2 per 1000
B. T. Lawson and I. A. Zealley: Adult ‘PICC’ Device may be used as a Tunnelled Central…
Catheter inserons
21 (100%)
Indicaon of procedure Access site
Parenteral nutrion Right IJV
4 (19%) 19 (90%)
Intravenous Anbiocs +/-
Le IJV
Anvirals
2 (10%)
17 (81%)
Fig. 4 Procedural data, complication rate and durability
catheter days). This case was a 9-year-old female with
Congenital Myotonic Dystrophy who had a gastrostomy
and colostomy for bowel dysfunction. Pseudo-obstruction
precipitated central venous access to facilitate administra-
tion of parenteral nutrition. On day 11, a temperature spike
led to blood cultures from the catheter which grew a strain
of Staphylococcus aureus, with which the stoma and gas-
trostomy sites were known to be colonised prior to catheter
insertion.
One patient (4.8%) experienced pain around the inser-
tion site on the day following central venous access
insertion: this resolved with simple analgesia and did not
necessitate premature catheter removal.
Figure 4 summarises the procedural data and overall
outcomes. Nineteen of the 21 TCVCs (90.4%) lasted for
the total intended duration of use.
Discussion
Demand for radiologically inserted vascular access devices
in children is increasing.
The most common paediatric vascular access device
inserted by an interventional radiologist is the PICC.
However, according to Krishnamurthy et al. [4], TCVCs
last longer than PICCs and are preferred when access is
required for more than 6 weeks duration. In a recent ret-
rospective cohort study conducted by Kovacich et al. [12]
649
Complicaon rate and
durability
Suspected Microbial
Elecve Removal Dislodgement
Colonisaon of Catheter
19 (90.4%) 1 (4.8%)
1 (4.8%)
Pain around inseron site
on Day 1
1 (4.8%)
No immediate or delayed
complicaons
Paent number = 19
18 (85.6%) Catheter days = 853
looking at PICC-associated complications in children
requiring long-term parenteral antibiotic therapy, there was
an overall complication rate of 4.6 per 1000 catheter days,
with catheter occlusion and dislodgement being the most
common reasons for premature PICC removal. On the
other hand, there are many institutions that use PICC
devices for long-term paediatric venous access, and there
are some data to support PICC devices having fewer
complications than TCVCs. Blotte et al. [13] carried out a
retrospective analysis comparing the complications of
Broviacs TCVC and PICCs in children with intestinal
failure receiving parenteral nutrition. When comparing
catheters with the same diameter, there were no significant
differences in infection or breakage rates. However, a
lower incidence of central venous thrombosis with the use
of PICCs is suggested. This correlates with evidence in the
literature, where risk factors for central venous thrombosis
include catheter size, location of the catheter tip and
associated catheter complications. Another prospective
randomised study by Cowl et al. [14] found no difference
in rates of infection, occlusion or dislodgement when
comparing PICCs with subclavian central catheters.
However, their use is associated with frequent compli-
cations resulting in premature catheter removal [1]. Infec-
tious complications include exit site or port infection,
tunnel infection and microbial colonisation of the catheter
(defined by either positive culture from the CVC with
negative peripheral blood culture, or positive catheter tip
123
650 B. T. Lawson and I. A. Zealley: Adult ‘PICC’ Device may be used as a Tunnelled Central…
Catheter
inserons
21
< 1 year 1 - < 5 years
6 8
3Fr SL 4Fr SL
3 8
4Fr SL
3 4
Fig. 5 Catheter size versus patient age
culture). Mechanical complications include inadvertent
dislodgement, catheter fracture, occlusion and venous
thrombosis [3]. Image guidance has been found to increase
procedure success rate and decrease acute complication
rates.
The 4.8% incidence (1.2 per 1000 catheter days) of
suspected microbial colonisation reported in our study is in
the lower range of reported rates in the literature. Garcia-
Teresa et al. [15] in a multicentre prospective study
examining children in a paediatric intensive care unit (ICU)
aged 0–14 years report a catheter-related blood stream
infection rate of 6.81% or 6.4 per 1000 catheter days.
Casado-Flores e al. [16] conducted a prospective study
looking at central venous catheterisations in children of
different ages in a paediatric ICU and found an infection
rate of 5.8%. Cruzeiro et al. [17] in a prospective study of
123
5 - < 10 years
7
4Fr SL
3
5Fr DL
Age Range in our
Study Populaon:
1.4 months to 9.6
years
SL = single lumen
DL = double lumen
consecutive catheterisations in children in a public hospital
report an 11.6% of suspected catheter-related infection.
Multiple studies have also been carried out looking at
complication rates of CVCs in neonates, with infection
rates varying from 0 to 46% [1, 18–27]. Battin et al. [27]
recently conducted a prospective audit assessing compli-
cation rates in a neonatal ICU. In total, 38% of babies
showed clinical signs of sepsis while their lines were in situ
but only 10% had positive peripheral or line cultures. On
the other hand, Ainsworth et al. [18] recently conducted a
meta-analysis looking at randomised controlled trials that
compared delivery of intravenous fluids via CVCs versus
peripheral cannulae in hospitalised neonates. In conclusion,
there was no evidence to suggest that percutaneous CVC
use increases risks of adverse events, particularly invasive
infection.
B. T. Lawson and I. A. Zealley: Adult ‘PICC’ Device may be used as a Tunnelled Central…
Dislodgement occurred in only one case (4.8%) in this
series, with a rate of dislodgement of 1.2 per 1000 catheter
days. We suspect that inadvertent dislodgement occurred
during a change of clothes by the child’s parents. The
current study identified a rate of dislodgement in the lower
range of that reported in previous studies. Central venous
catheter dislodgement has been found to be more frequent
in younger patients [1]. A retrospective study by Tavis
et al. [3] comparing delayed complications of surgically
versus radiologically placed CVCs in paediatric oncology
patients quotes a rate of dislodgement of 16.7% amongst
radiologically placed CVCs. Nosher et al. [28] examining a
sample of paediatric CVCs predominantly placed for
chemotherapy reported rates of dislodgment at 12% (0.82
per 1000 catheter days). Wiener et al. [29] in a large,
multicentre study combining data from ports and CVCs
placed for chemotherapy in children reported rates of dis-
lodgement ranging from 2.8 to 24%. This suggests that
despite lacking a Dacron cuff and with only a proprietary
adhesive anchoring mechanism in place, these non-cuffed
devices are reasonably secure. We attribute this infrequent
rate of dislodgement to the fact that these tunnelled
catheters can be tucked away safely under the child’s
clothing and are less likely to get accidentally pulled out in
comparison with peripherally inserted catheters.
The results not only indicate our technique to be safe
with an acceptable low complication profile, but also offer
an advantage of greater convenience in comparison with
conventional paediatric TCVCs. Ninety per cent of these
catheters lasted for the total intended duration of use and
remained in situ until no longer required. It is not clear
what is responsible for the apparent security of the device,
but experience with this model and brand of adhesive
device in adult PICCs suggests that the adhesive device
alone provides durable device retention without suturing or
the presence of a subcutaneous retention cuff. It is, how-
ever, recommended that the adhesive device be replaced
expertly when indicated by the state of the dressings.
Catheter removal in our technique is less complex. The
catheter can be removed simply by pulling it out, and this
does not require general anaesthesia because it does not
cause any discomfort. Another advantage over standard
PICCs is that the device gets tucked away safely under
clothing, away from inquisitive fingers. The limitations of
the current study include the retrospective non-randomized
study design and the modest sample size.
Future prospective studies comparing this novel tech-
nique with standard PICCs and conventional TCVCs
placed over a similar time period would be of value to
confirm equal utility, comparable complication rate and
possibly a better cosmetic result in relation to healing of
the chest wall scar. Although the subgroup of five patients
(24%) who were less than 1 year of age or less than 10 kg
651
in weight were not analysed separately, none of these
patients sustained delayed complications in our study
population. To the best of our knowledge, although we are
aware anecdotally of other units employing similar tech-
niques, we are not aware of any priorly published report
describing this simple technique.
Conclusion
Using an adult PICC device as a TCVC in infants and
children, including children less than 1 year of age or
weighing less than 10 kg, appears to be a safe technique
with an acceptable complication profile. The principal
advantage of this technique is that the catheter removal
technique is less complex than that of standard TCVC. The
catheter can be removed simply by pulling it out, and this
does not require general anaesthesia.
Compliance with Ethical Standards
Conflict of interest All authors declare that they have no conflict of
interest.
Informed Consent For this type of study, formal consent is not
required.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
made.
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